History of Psychiatry

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Carl Wernicke and the concept of 'elementary symptom'

A. Krahl and M. Schifferdecker
History of Psychiatry 1998; 9; 503
DOI: 10.1177/0957154X9800903605
The online version of this article can be found at:
http://hpy.sagepub.com/cgi/content/abstract/9/36/503

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History of PsychIatry,

ix

503-508. Pnnted
(1998),503-

In

England

Historical vignette

Carl Wernicke and the concept of

elementary symptom
A. KRAHL* and M. SCHIFFERDECKER
Re-written by
A. BEVERIDGE

Examination of contemporary medical conference papers reveal that the

German clinician, Carl Wernicke, conducted a unique on-going inquiry into
psychiatric nosology. Wernicke was searching for what he called the elementary
symptoms of mental disorder, or, in other words, the single psychopathological
feature, from which all others arose. From 1892 onwards, he postulated a
variety of such elementary symptoms. Wernickes theory makes sense in terms
of such categories as anxiety-psychosis and hallucinosis. His work contrasts
with that of Kraepelin and also with modern diagnostic criteria. Neither
Wernicke nor his followers pursued the theory of elementary symptoms, but an
examination of his work sheds light on modern ideas about diagnosis.

Carl Wernickes work

psychiatrist
Carl Wernicke (1848-1905) is known primarily
as a

as a

pioneering neurologist,

is remembered in such terms as Wemickes area, Wemickes

aphasia, and Wernickes encephalopathy. He turned his attention to
psychiatry only in 1885, when he was appointed director of the psychiatric
wing of All Saints Hospital in Breslau. His new position allowed him
extensive study of psychiatric patients (2), and he drew on this to develop
and his

name

* Address for correspondence: Klinik und Poliklinik fur Neurologie und Psychiatrie, JosephStelzmann-Strasse 9, D- 50924 Koln, Germany.

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504

important new ideas, which he published in a textbook (9) and in the form of
case histories (13). We do not have access to private letters, diaries or case
notes, but we are able to examine conference proceedings from the period
which reveal evidence of the development of Wernickes thinking.
From

exaggerated idea to elementary symptom1

At the triennial conference of the herein ostdeutscher Irrenrzte,2 there was not
only the presentation of papers, but there was also the opportunity for the
informal exchange of ideas and comparison of clinical notes. The
conferences at Breslau were usually chaired by Wernicke. From 1888, the
conference proceedings were published in the Allgemeine Zeitschrift fiir
Psychiatrie und psychisch-gerichtliche Medizin.3
At the fifty-ninth conference, on 19 July 1892, Karl Kahlbaum from
Gorlitz described his new concept of paranoia, which was based on a
psychiatric report he had written. In the animated discussion which ensued,
Wernicke, who appears to have been familiar with the case, took issue with
Kahlbaums diagnosis of pseudoparanoia. Wernicke contended that the case
was an example of an ide fixe, or, as one might usefully call it, a supervalent
idea.4 He continued: Every symptom was secondary to the &dquo;supervalent
idea&dquo;; this was a case ... of &dquo;logical delirium&dquo;: both affect and behaviour
were simply the consequence of the idea(8).
In his remarks, Wernicke argued that there was a single, fundamental
symptom, and that all the other symptoms derived from it. This was the first
occasion that Wernicke outlined his theory, and, in retrospect, his comments
can be seen as introducing a new approach to nosology. However, it was to
be another year before Wernicke actually used the term elementary
symptom. Subsequent conference proceedings allow us to follow its
development. The sixtieth meeting of the Verein ostdeutscher Irrenarzte took
place on 26 November 1892 in Breslau, and there were thirty-two delegates.
According to the proceedings: Dr Wernicke exhibits (...) 14 patients from
his clinic, the first two as examples of supervalent ideas. He diagnoses the
remaining 12 as cases of psychosis of motility. He reserves the details of his
observations for a forthcoming publication (10).
The delegates observed the fourteen patients, but no papers were read.
However, at the conference at Sorau on 25 June 1893, Wernicke replied to

Elementarsymptome.

Eastern German League for Abnormal Psychology.

General Journal of Psychiatry and Psychiatric-Legal Medicine.
4
Wernicke was employing the notion of supervalent idea/overcharged idea (
überwerthige Idee) as
early as 1890, in the evaluation of a case of persecution complex. So he reported in an 1897 essay,
Zur klinischen Abgrenzung des Querulantenwahnsinns (Toward a clinical definition of
persecution complex), Monatsschrift für Psychiatrie und Neurologie, Bd. II, S.10.
3

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505

questions

about his views:

Since the question has been raised today, I would like

say just a few
words about supervalent ideas and underestimation.5toThere are cases
where an elementary symptom is all that comprises the disorder; for
example, in cases of anxiety, unhappiness, or hallucinosis, or where the
entire disorder is limited to a flight of ideas; in other words, there are
6
cases where an elementary symptom dominates the entire disorder.6
There are also cases where elementary symptoms exist in combination;
such cases are more frequent. So it is quite common to find supervalent
ideas in cases of melancholy, which is characterized by numerous such
ideas. However, the opposite condition - mania - can be characterized in
terms of underestimations. By this I mean that certain ideas lose their
importance. For example, ideas about discretion, honesty or decency,
which the patient formed when he was younger, may now be considered
as overestimations. One sees this all the time in patients with mania.

(11)
Insofar as he equated a particular symptom with a particular disorder,
Wemicke was drawing on a commonly held principle of general medicine. At
this stage, he was not seeking to comment on aetiology, and he remained in
the German tradition of meticulous clinical description (6). Later, however,
he went on to develop his complicated sejunction theory, which was based
on his association theory. Here he attempted to establish a strict relationship between psychopathological symptoms and cerebral pathology (4).
From elementary symptoms to anxiety-psychosis
At the sixty-sixth meeting of the herein in Breslau on 24 November 1894,
Wemicke developed his ideas about the concept of anxiety-psychosis further,
but he remained consistent with his earlier pronouncements:
It is a clinical necessity that we define such a group of disorders, since
there are innumerable cases where a pathological fear is the dominant
symptom, and where this symptom underlies all the others. The delusions
that accompany the psychosis may be visual or auditory. The basic
content of all such delusions is fear: the patient fears that his or her life is
threatened, often in fantastic ways; or the patient fears a loss of honour, as
indicated in the hostility of voices he or she hears; or the patient suffers an
inferiority complex, i.e. an imagined loss of status; or, finally, the patient

5 Idee.
unterwerthige
6
Original version:

... Es giebt Fälle, in welchen ein Elementarsymptom die ganze Geisteskrankheit ausmacht; es giebt ohne Zweifel Fälle, in denen die ganze Geisteskrankheit in nichts
anderem als in Angst besteht, andere in denen sie nur in Hallucinationen besteht, in anderen wieder
in Unglücksgefühl, wieder andere in denen die ganze Krankheit sich fast erschöpft in Ideenflucht; es
giebt also Fälle, in welchen ein Elementarsymptom das ganze Krankheitsbild beherrscht.

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506
that the future is hopeless. We can describe all such delusions as
delusions of anxiety, because we often observe them in the context of
anxiety. One could also postulate that there was a specific type of
psychosis, namely hypochondriacal psychosis, in which hypochondriacal
ideas predominate ... Simple, uncomplicated cases almost always offer
the best prognosis. (12)

imagines

The historical significance of the concept

In contrast to Wernickes theory of the elementary symptom, Kraepelin
sought to describe all the clinical aspects of a particular disorder (3). In fact,
Wernickes approach only successfully accounted for two conditions: anxiety
psychosis and hallucinosis. In the former, all the symptoms derived from the
underlying anxiety and they grew worse as the anxiety increased. In the
latter, secondary symptoms developed in response to the hallucination. Both
conditions were characterized by anxiety, but in different ways. In anxietypsychosis, the symptoms were secondary to anxiety, whereas in hallucinosis,
anxiety was secondary to the symptoms.
As we have seen, Wernicke mentioned two other states which he sought to
explain in terms of overestimations. These were unhappiness and flight of
ideas. While the feeling of unhappiness in the context of depression is almost
invariable, it has little aetiological significance, and Wemicke was unable to
extend his argument or to establish a psychosis of unhappiness. Wernickes
theory of elementary symptoms had more success in explaining flight of
ideas. Mania may present primarily with flight of ideas. Nevertheless, this
symptom is not confined to one discrete mental disorder, but may occur in a
variety of conditions.
There are three reasons why Wernickes theory of the elementary
symptom met with little success. Firstly, he did not pursue his idea,
preferring instead to devote time to his sejunction theory. Secondly, in
keeping with the traditions of German psychiatry (6), he merely described
clinical vignettes, unlike Kraepelin or Kahlbaum, who delineated syndromes
or discrete disorders. Wernicke was thus unable to distinguish between the
physical or psychological causes of symptoms (13). Finally, anxiety, which
Wemicke placed at the centre of his clinical descriptions, is seen in nearly
every mental disorder. The theory demands that all symptoms derive from
one elementary symptom, but it is difficult to decide which symptom
should be given priority. In practice, Wernickes system was seriously flawed
and was unable to illuminate diagnosis or aetiology.
Nevertheless, Wernickes hypothesis demonstrates that he was an original
and independent thinker, and no comparable theory can be found in the
work of Kraepelin, the French clinicians or, indeed, in any of the
contemporary literature. Although he was a follower of Wernicke, Karl
Leonhard ignored the concept of elementary symptoms; rather he sought to

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507

incorporate Wernickes psychopathological categories into Kraepelins binary

system. Thus he renamed anxiety-psychosis, cycloid psychosis, which he
believed resembled schizophrenia in its symptomatology, but also manicdepressive psychosis in the periodic course that it followed (5). However,
Leonhard abandoned Wernickes original reason for proposing such
disorders.
The

elementary symptom today

Every experienced psychiatrist has witnessed anxiety in patients. However, it
is methodologically difficult to provide operational diagnostic criteria for
anxiety, because it is part of normal experience and resists precise clinical
description. The theory of elementary symptoms plays no role in modem
discussions about nosology and aetiology, but it does have a place in modem
psychopharmacology with its notion of target symptoms. Clinical psychopharmacology has been more orientated towards treating particular
symptoms than diagnostic categories. The principle of treating a target
symptom rests on the assumption that other symptoms are, in some sense,
dependent on the original target symptom. Such theorizing has obvious
parallels with Wernickes system.
Even if it is impossible to determine the aetiology of anxiety-psychosis,
the concept does have a bearing on current practice. Every experienced
clinician has observed the coexistence of acute psychosis with high levels of
anxiety. Tranquillizers are used to treat the anxiety (7), and the resultant
calming effect is often accompanied by an improvement in the psychotic
symptoms. Perhaps if Wernicke had been able to test his hypotheses by
means of an effective psychopharmacology, the influence of his theories
might have been greater.
Conclusions
The proceedings of the Verein ostdeutscher Irrenarzte reveal a particularly
creative phase in Carl Wernickes career at Breslau. Before he developed the
sejunction theory - a doctrine which was to be crucial to his later work - he
pursued the hypothesis that some mental disorders are manifest by an
elementary symptom that forms the basis for all the other symptoms. His
attempts to clarify the concept of anxiety-psychosis between June 1893 and
November 1894 were clearly based on meticulous clinical observation. His
observations stimulated a burst of creative theorizing, but unfortunately, he
did not immediately commit his thoughts to writing.
Tracing the evolution of Wernickes thinking is not merely of historical
interest, but also provides an insight into modern diagnostic trends. Every
revision of modem diagnostic manuals results in an addition to the number
of mental disorders (1, 14). As a consequence, there is a desire for simplification and clarity. Wernickes crucial dictum that the clinician should
identify the dominant symptom in any given mental disorder has parallels in

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508

modem practice. Each new manual tries to accommodate an ever-expanding

volume of research and clinical theory. Clearly, even where diagnostic criteria
are accorded equal conceptual weight, there might be practical and empirical
reasons to weigh them differently in specific cases; in other words, to select
certain symptoms as being more elementary. It is too early to say whether
there will be efforts to simplify diagnostic manuals. Perhaps it is more likely
that the manuals will continue to increase in size as they attempt to remain
comprehensive, and thus become even less comprehensible. On the other
hand, improvements in drug therapy can only proceed in tandem with a
better understanding of what constitutes the target symptom in a particular
disorder. Such improvements might lead to changes in ideas about aetiology
and diagnosis. Such potential developments, presently only implicit in
empirical research, would be in the tradition that Carl Wernicke established
at the turn of the century.
REFERENCES
1. American

Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th edn
(Washington, DC: American Psychiatric Association, 1994).
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Wochenschrift, xlii (1905), 927-8.
3. E. Kraepelin, Psychiatrie, ein kurzes Lehrbuch für Studirende und Aerzte (Leipzig: Abel, 1893).
4. Mario Lanczik and G. Keil, Carl Wernickes localization theory and its significance for the
development of scientific psychiatry, History of Psychiatry, ii (1991), 171-80.
5. K. Leonhard, Aufteilung der endogenen Psychosen (Berlin: Akademie, 1986).
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Gegenüberstellung, Fortschritte der Neurologie Psychiatrie, lxii (1994), 137-6.
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Angstsyndrome (Stuttgart, New York: Schattauer, 1988).
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19 June 1892, Allgemeine Zeitschrift für Psychiatne und psychisch-genchtliche Medizin (1893),
486-9.
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Carl Wernicke, remarks at the 62nd meeting of the Verein, Sorau, 25 June 1893, Allgemeine
Zeitschrift für Psychiatrie und psychisch-gerichtliche Medizin (1895
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b
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c
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1998 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.